"D

on't run with scissors in your hands," my mother used to warn, "or you'll fall and hurt yourself." Today, the "scissors" in the hands of clinicians caring for wounds are those outdated, unfounded wound care practices we've been running with for years. Our healthcare system will no longer tolerate nor can it afford to let us run around with these scissors. We must put them down, or more than just our patients will feel the pain of it.
       Nurses spend more time with patients than other members of the healthcare team. For this reason, nurses caring for patients with wounds must expand their definition of pain to include the mental, emotional, and financial distress associated with their wound care today.
       Wherein lies the financial pain associated with wound care? New product development costs are enormous; malpractice suits are common and continue to spiral out of control. Belt tightening by providers, increased regulations, and a nursing shortage make the already daunting job of wound care even more challenging. Inadequate provider education about state-of-the-art wound care fosters the development of preventable pressure ulcers, wound infections, unnecessary amputations, as well as the misuse and overuse of wound care products and supplies. Ten-year-old "gold standard" AHCPR guidelines remain absent in many organizations' policies and procedures manuals. Medicare and Medicaid providers make headlines in newspapers and on television, as surveyors and attorneys find evidence of neglect, malpractice, or even intent to harm patients with chronic wounds.
       Patients with wounds in our overburdened healthcare system may be unproductively treated for long periods of time due to multiple inconsistent caregivers, lack of follow up, inaccurate wound care knowledge,1 and a disorganized approach to care. Clinicians function under erroneous assumptions, such as, "These kinds of wounds never heal," "It will take months or even years for this wound to heal," or "We can't afford the dressings we need."
       Each day in every clinical setting, patients with chronic wounds arrive with hope of a cure. Well-meaning clinicians read their medical records and listen to the patients' litany of previous attempts by multiple healthcare professionals to treat and heal their wounds and come to the unfortunate conclusion that these wounds are simply "unhealable" regardless of the care they provide. Worse is the feeling that there are advanced technologies available for these patients but no means to pay for such technologies. Such wounds linger and continue to be treated ineffectually (even, perhaps, with re-injury at each dressing change) without accurate monitoring of their improvement or deterioration or involvement by other members of the interdisciplinary team. All the while, the cost of these patients' care continues to increase as more and more resources are used.
       Caregivers failing to provide adequate care often use the excuse of being too busy, not having enough help, and/or not having patient/family cooperation.2 The "system" is also blamed--too many regulations and documentation requirements and "unrealistic" expectations from the Centers of Medicare and Medicaid Services (CMS). But I challenge the criticism of the CMS as an excuse for our shortcomings.
       Where, we wonder, does the CMS get all the information they use to establish policy and payment levels? After years of researching and reporting on government healthcare policy, I can answer that question unequivocally. The information comes from you, the clinician--from the caliber of documentation you record in the patient's medical record, from the check-off sheets filled out each and every day on every shift, or even from the intake sheets you complete as a clinical investigator for a manufacturer's clinical trials. Claims and documentation of patient teaching that was or was not provided and compilation and analysis of the MDS and OASIS data become the platform upon which future national coverage and payment policies will be built.
       Unnecessary and unproductive increased consumption of expensive resources escalates the cost of wound care. The pain of these costs is felt at every level: by patients who are unable to access healthcare professionals who have the knowledge and expertise to help them; by clinicians who operate under the misconception that some dressings are "too expensive" to use; and by our healthcare system's relentless quest to provide the best wound care at the lowest price.
       The reality is that increased resource utilization and poor reimbursement can make acceptance of new technologies less appealing to providers, physicians, nurses, and patients if they are financially unattractive or, at a minimum, budget neutral.
       But there is light at the end of the tunnel that may offer systemic relief to this pain. Because they are being approached by wound care professionals, patients with wounds, and manufacturers of wound care products, regulators and payers are listening and learning more about wound care. The FDA has recently approved some cutting edge wound care technologies, such as bioengineered skin and skin substitutes,3 for which the CMS has established payment codes4 and begun the process of establishing new coverage policies on a local and national level. Cracks are beginning to appear in what have traditionally been the barriers for access to new technologies and products--coverage and payment policies?due to the refined quality of the clinical studies behind them. This is proof that the CMS is keeping up with the technology associated with modern wound healing.
       Overall, we have made a quantum leap in the care of wounds over the last two decades, and for that, the wound care community should be proud. The regulators and payers also deserve credit for their willingness to listen and accommodate healthcare policy to meet changing needs. Even so, the pain in our healthcare system--and wound care in particular--persists. We must acknowledge the pain and treat it systemically in order that more patients have the ability and opportunity to access the high caliber of wound care available in our country today.